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Lynda EnderDavid Thomason, Ph.D. AGE DirectorPresident/Lead Consultant The Senior SourceAdvocacy Gauge Changes in Medicare, Medicaid and Health Care Delivery.

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Presentation on theme: "Lynda EnderDavid Thomason, Ph.D. AGE DirectorPresident/Lead Consultant The Senior SourceAdvocacy Gauge Changes in Medicare, Medicaid and Health Care Delivery."— Presentation transcript:

1 Lynda EnderDavid Thomason, Ph.D. AGE DirectorPresident/Lead Consultant The Senior SourceAdvocacy Gauge Changes in Medicare, Medicaid and Health Care Delivery for Aging Texans

2 Why Reform Health Care? Lots of people not insured – 50.7 million A wasteful system that spends too much on emergency room care, unneeded tests, and care that does not work Lack of emphasis on prevention and looking out for our health

3 Uninsured Texans by Age Group, 2008 Source: U.S. Census

4 Basics of the Affordable Care Act Expands coverage to 50.7 million Americans who are currently uninsured Requires U.S. citizens and legal residents to have qualifying health coverage. Those without coverage pay a tax penalty of $695 per year up to a maximum of three times that amount per family or 2.5% of household income Expands Medicaid to all individuals under age 65 with incomes up to 133% Federal Poverty Level based on modified adjusted gross income Create state-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges, administered by a governmental agency or non-profit organization, through which individuals and small businesses with up to 100 employees can purchase qualified coverage. The enrollment begins Oct. 1, State bills: SB 1057 and SB 1795 Eliminates lifetime caps Prohibits pre-existing condition exclusions

5 Closing the Rx “Doughnut Hole”: Beginning in 2011, seniors receive a 50% discount on their brand-name prescription drugs when they fall into the doughnut hole, and by 2020 the doughnut hole will be completely eliminated. Medicare Part D: Expands the Part D low-income subsidy, which will significantly help struggling seniors afford their health care costs and makes it easier to appeal coverage denials Medicare Changes Affecting Older Adults

6 Medicare Changes Affecting Older Adults cont’d New preventive benefits: Free annual wellness exams and no co-payments and no deductibles for preventative services such as mammograms, colonoscopies, bone density measurement, pap smears and pelvic exams, blood tests for heart disease, depression screenings, obesity screenings, nutritional therapy and diabetes screening, flu and pneumonia vaccine (January 2011) Reducing payments to Medicare Advantage plans: saves about $136 billion and plans must notify policy holders by Sept. 30 of changes in plans. New annual enrollment period is October 15 – December 7.

7 Change to Patient Centered Care Better Chronic Care: Funds patient-centered care which encourages doctors to coordinate care and improve quality, creating incentives for providers to work together and reduce wasteful care like repeated tests Better Care After a Hospital Discharge: Links payments between hospitals and other care facilities to promote discharge planning and transitional care

8 2012 General Election Breakdown The PrimariesThe Primaries –The most competitive races were in the primaries –Most conservative Republicans and most liberal Democrats winning elections. Texas HouseTexas House –44 new members elected –95 Republicans – 55 Democrats –Over half of the House new over the last two elections Texas SenateTexas Senate –6 new members elected –19 Republicans – 12 Democrats

9 State Legislative Session The Budget :The Budget : –Estimated $8B in additional state revenue. –Agencies instructed to submit baseline spending requests and plans including 10% cuts. –Spending limited to $77.9B from $70B in –Supplemental appropriation of $4.8B to Medicaid. Health care topped the agenda.Health care topped the agenda. Medicaid ExpansionMedicaid Expansion

10 Aging Bills Filed #1Human Services – 242 filed #2HHSC – 237 filed #3Health Care Providers – 181 filed #4 Medicaid – 110 filed #5Managed Care – 45 filed #6 Aging – 39 filed #7DADS – 32 filed #8Assisted Living Facilities – 19 files #9Nursing Facilities – 16 filed #10 Long-Term Care – 11 filed

11 Medicaid Reimbursement Rates HHSC reported reimbursement rates where under- funded by 17%. $ vs. $121.00HHSC reported reimbursement rates where under- funded by 17%. $ vs. $ HB 10 - Emergency Supplemental AppropriationsHB 10 - Emergency Supplemental Appropriations $4.8B approved to fund Medicaid through $4.8B approved to fund Medicaid through Budget Deal Budget Deal –2% increase in –4% increase in 2015.

12 STAR+PLUS Expansion - Senate Bill 7 STAR+PLUS Medicaid Managed Care will be expanded to long-term care and nursing homes.STAR+PLUS Medicaid Managed Care will be expanded to long-term care and nursing homes. The state will contract with managed care organizations to manage care and payment in nursing homes.The state will contract with managed care organizations to manage care and payment in nursing homes. HHSC will be responsible for setting the reimbursement rate.HHSC will be responsible for setting the reimbursement rate. A 15 person Advisory Committee will oversee a two-part implementation (3 non-profit providers).A 15 person Advisory Committee will oversee a two-part implementation (3 non-profit providers). Quality-based payment system and incentives.Quality-based payment system and incentives. Implementation set for 2015.Implementation set for 2015.

13 Companion Bills to SB 7 SB Relating to a utilization review process for managed care organizations participating in the STAR + PLUS Medicaid managed care program. SB 58 - Relating to integrating behavioral health and physical health services provided under the Medicaid program using managed care organizations.

14 Fighting Medicaid Waste & Fraud SB 8 - Relating to the provision and delivery of certain health and human services in this state, including the provision of those services through the Medicaid program and the prevention of fraud, waste, and abuse in that program and other programs. Would ensure that providers found guilty of Medicaid fraud in Texas or other states would be barred from participating in the state’s program, strengthen prohibitions against marketing to Medicaid patients, add medical transportation services to managed care and enable the Health and Human Services Commission's Office of Inspector General to establish a new data system to catch Medicaid fraud earlier.

15 Fighting Medicaid Waste & Fraud cont. SB 746 – Relating to unlawful acts against and criminal offenses involving the Medicaid program. SB 1542 – Relating to clinical initiatives to improve the quality of care and cost- effectiveness of the Medicaid program.

16 Other Medicaid Bills SB 45 - Relating to the provision of employment assistance and supported employment to certain Medicaid waiver program participants. SB Relating to the establishment of a reuse program for durable medical equipment provided to recipients under the Medicaid program.

17 Thank You! Please, fill out the Evaluation.

18 “The greatest wealth is health.” Virgil “The greatest wealth is health.” Virgil Lynda EnderDavid Thomason, Ph.D. AGE DirectorPresident/Lead Consultant The Senior SourceAdvocacy Gauge 3910 Harry Hines Dallas, Texas , x6113 Helpful Websites:


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